SUMMARY REPORT
MEETING 31
Date:
Time:
Location:
Hosts:
Topic:
Presenter:
Wednesday, February 26, 2014
11:00AM – 12:00PM PST
Conference Call
UCLA Integrated Substance Abuse Programs (ISAP) & CA
Department of Health Care Services (DHCS)
Will They Turn You into a Zombie? What Clinicians Need to Know
about Synthetic Drugs
Beth Rutkowski, MPH
Associate Director of Training/Epidemiologist
UCLA Integrated Substance Abuse Programs
Logistics
 Summary and materials discussed from the previous ILC meetings are
available at http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html. Subsequent meeting materials will continue to be
posted on this site.
 The next ILC meeting will be held on March 26, 2014 at the County
Alcohol and Drug Program Administrators' Association of California
(CADPAAC) Quarterly Meeting in Sacramento, CA. Future meetings are
planned for 11:00AM (PT) on the 4th Wednesday of every month, unless
otherwise noted.
ILC Meeting 31 Topic:
Will They Turn You into a Zombie? What Clinicians Need to Know about
Synthetic Drugs
Topic Introduction – Brandy Oeser, MPH – UCLA ISAP
 For today’s learning collaborative, Beth Rutkowski will present on what
clinicians need to know about synthetic drugs. This topic has relevance
and practice implications for all types of providers, whether they are
working in integrated primary care or in specialty MH and SUD treatment
settings. We thank Ms Rutkowski for her time and effort to present this
topic to help inform ILC participants.
Beth Rutkowski, MPH
Associate Director of Training/Epidemiologist
UCLA Integrated Substance Abuse Programs
Summary

Key Topics
o Characteristics and effects of synthetic drugs, most notably synthetic
cannabinoids and synthetic cathinones.
o Neurobiology of synthetic drug use, and the differential impact of synthetic
drugs vs. “classic” illicit drugs, such as marijuana and cocaine.
o Availability and patterns of synthetic drug use in the United States.
o Strategies to communicate the dangers involved with synthetic drug use.

Review of Synthetic Drugs
o Categories of “Designer” Psychoactive Substances
 Psychedelics
 Cannabinoids
 Stimulants
 Dissociatives
 Sedatives
o From the term “Bath Salts” to…
 Synthetic cathinones
 2C- phenethylamines
 Tryptamines
 Piperazines
 Dissociatives (related to ketamine and PCP)
 Opioids (related to morphine, fentanyl, and heroin)
o Synthetic Drugs
 Not really “Spice,” “Bath Salts,” “Incense,” or “Plant Food”
 Chemically-based; not plant derived
 Complex chemistry
 Constantly changing to “stay legal”
 Need to prove “intended to use” to convict in some areas
o Marijuana (Cannabis) vs. Synthetic Cannabinoids
 Synthetic Cannabinoids
 Wide variety of herbal mixtures
 Marketed as “safe” alternatives to marijuana
 Brand names include: “Spice,” “K2,” fake weed, “Yucatan Fire,”
“Skunk,” “Moon Rocks,” herbal incense, “Crazy Clown,” “Herbal
Madness”
 Labeled “not for human consumption”
 Mainly abused by smoking (alone or with marijuana); may also be
prepared as an herbal infusion for drinking.
 Many of the active chemicals most frequently found in synthetic
cannabis products have been classified by the DEA as Schedule I
controlled substances, making them illegal to buy, sell, or possess.


Multiple “generations” of drugs.
Cases reported of kidney damage linked to synthetic cannabinoids;
seizures and psychotic behavior in pregnant woman
o Khat vs. Synthetic Cathinones
 Synthetic Cathinones
 Could be MDPV, 4-MMC, mephedrone, or methylone
 Sold on-line with little info on ingredients, dosage, etc.
 Advertised as legal highs, legal meth, cocaine, or ecstasy
 Taken orally or by inhaling
 Serious side effects include tachycardia, hypertension, confusion or
psychosis, nausea, convulsions
 Labeled “not for human consumption” to get around laws prohibiting
sales or possession
o Synthetic Drug Testing Protocol – What to Consider
 Questions to consider when selecting a toxicology laboratory:
 For which synthetic drugs should you test?
 How many derivatives/formulations can
the laboratory detect with
their test?
 Are the newest generations
(4th and above such as the AM,
 XLR, and UR versions) detected?
 How much does the test cost?

Effects of Synthetic Drugs
o Effects of Synthetic Cannabinoids
 Most symptoms are similar to cannabis intoxication: tachycardia,
reddened eyes, anxiousness, mild sedation, hallucinations, acute
psychosis, memory deficits
 Effects not typically seen after cannabis intoxication: seizures,
hypokalemia, hypertension, nausea/vomiting, agitation, violent
behavior, coma
 Unlike cannabis, synthetic cannabinoids have no therapeutic effects
o Effects of Mephedrone
 Intended effects: euphoria, stimulation, enhanced music appreciation,
decreased hostility, improved mental function, mild sexual stimulation
 Unintended (adverse) effects: bruxism (teeth grinding), delusions,
dilated pupils, hallucinations, poor concentration, poor short-term
memory, problems focusing visually
o Effects of Methylone
 Anorexia, anxiolysis/anxiogenesis, bruxism (teeth grinding), central
nervous system stimulation, de-realization/de-personalization, dilated
pupils, euphoria or dysphoria, hallucinations, hypertension (high bp),
hyperthermia, increase in sociability, insomnia, nausea and vomiting,
nystagmus, psychosis, restlessness, sweating, tachycardia (rapid
pulse), trismus (inability to open the mouth)

Neurobiology of Synthetic Drug Use
o “Classic” Cannabinoids and Synthetic Cannabinoids
o “Classic” Stimulants and Synthetic Stimulants
o Synthetic Cathinones

Epidemiology of Synthetic Drug Use
o Emerging Drug Items Identified in U.S. NFLIS Forensic Labs
 Indicates increasing use of synthetic cannabinoids and synthetic
cathinones
 Increase in number of different chemical formulations which have been
seized and identified for synthetic cannabinoids and cathinones by
forensic laboratories located throughout the United States.
o Calls Received by U.S. Poison Control Centers for Human Exposure to
Synthetic Marijuana
 According to the American Association of Poison Control Centers,
2,906 calls relating to human exposure to synthetic marijuana were
received in 2010. Twice that number (6,968) were received in 2011,
and 5,205 received in 2012, and 1,413 had been received as of June
30, 2013
o Use of Synthetic Drugs by U.S. Students
 More high school students report using synthetic marijuana than any
other substance besides alcohol and marijuana, according to data from
a survey of 9th to 12th graders recently released by the Partnership for
a Drug-Free America
o Emergency Room Visits Related to Synthetic Cannabis and Cathinones:
DAWN, 2011
 A higher percentage of synthetic cannabinoid patients were under the
age of 21, as compared to synthetic cathinone patients. The synthetic
cathinone patients were less likely to be discharged home and 12%
were sent to the Intensive Care Unit or to a substance abuse treatment
program

Other Notable Synthetic Drugs – “New and Old”
o MDMA (Ecstasy)
 “Molly” (usually is not a pure form of MDMA, but may be a drug that
can be very dangerous since its contents are unknown)
o Piperazines
o 2C-Phenethylamine
o Dextromethorphan (DXM)
o Kratom
o Krokodil
o Benzo Fury
o “Syrup”
o Dabs, BHO, Honey, Budder

Sample Treatment Protocols and Concluding Thoughts
o Synthetic Cannabinoids – Clinical Presentation
 Persistent depression
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Memory problems (can last for several weeks)
Blunted affect
Difficulty focusing
Difficulty participating in clinical until stabilized
Users also report elevated mood, relaxation, and altered perception
Psychotic effects, such as extreme anxiety, paranoia, and
hallucinations
o Sample Clinical Treatment Protocol for Synthetic Cannabinoid Users
 Direct individual to emergency room via ambulance
 Consult a regional Poison Control Center
 Acute management consists of:
 Supportive care with the use of benzodiazepines, if needed, to
control agitation and anxiety
 Observe until resolution of abnormal vital signs, vomiting, and
psychiatric symptoms
o Recognizing Synthetic Cathinone Intoxication
 Present with severe sympathetic stimulation: hypertension,
hyperthermia, seizures, tachycardia
 Present with profoundly altered mental status: agitation, hallucinations,
paranoia, severe panic attacks, suicidal behavior
o Sample Clinical Treatment Protocol for Synthetic Cathinone Users
 Supportive care
 Aggressive sedation with benzodiazepines (for agitation, seizures,
tachycardia, and hypertension)
 Significant hyperthemia may require passive or active cooling
 Lab studies including electrolytes, renal and liver function tests, cardiac
markers, and creatine kinase should be considered

In Summary: Key Points
o Lack of information on the chemical contents, dosage levels, and
consistent quality of the products is a major problem since users are
taking drugs about which they know little, which makes provision of health
care for adverse events more difficult.
o Despite widespread Internet availability and use among certain
populations, health care providers remain largely unfamiliar with synthetic
drugs and the multiple variations which have appeared recently.
o Research is needed to better understand the side effects and long-term
consequences associated with the use of synthetic cannabinoids and
synthetic cathinones.
o More toxicological identification of these new drugs, more information on
the sources of them, as well as their distribution and patterns of use is
needed to curtail future increases in use.
o We do not have human neurobiological data or long-term data, but we can
extrapolate a few key points from the existing literature:
 Synthetics vs. Classics: Neurobiological concerns hold up, plus more
 In all cases, neurobiology predicts abuse potential

In general, synthetic versions are not a simple substitute for “classics”
– effects tend to be more intense (including side effects), some
unexpected, and some new interactions that were not a concern before
APPENDIX 1 – ATTENDEES
COUNTY PARTICIPANTS
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
Andrew Williams (Solano)
Brett O’Brien (Orange)
Clint Huffman (Tuolumne)
Margot Carabali (Los Angeles)
OTHER PARTICIPANTS
 Terri Viana (The Villa Center)
DHCS PARTICIPANTS
 Craig Chaffee
UCLA PARTICIPANTS




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Beth Rutkowski (presenter)
Brandy Oeser
Cheryl Teruya
Elise Tran
Valerie Pearce Antonini
APPENDIX 2 – AGENDA AND RELEVANT MATERIALS


Topic Discussion – Will They Turn You into a Zombie? What Clinicians
Need to Know about Synthetic Drugs
Q and A
MATERIALS FOR THIS MEETING

PPT Presentation – Will They Turn You into a Zombie?
What Clinicians Need to Know about Synthetic Drugs
RELEVANT LINKS

ATTC Synthetic Drug Training Package, Full Curriculum
http://www.uclaisap.org/slides/synthetic-drug-trainingpackage.html
Copies of materials can be found at UCLA ISAP’s ACA Resources Website:
http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html.